Provider Demographics
NPI:1710030341
Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Entity Type:Organization
Organization Name:GENESEE VALLEY GROUP HEALTH ASSOCIATION
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT REGIONAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-336-4841
Mailing Address - Street 1:800 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-2604
Mailing Address - Country:US
Mailing Address - Phone:585-338-1400
Mailing Address - Fax:585-336-4845
Practice Address - Street 1:800 CARTER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-2604
Practice Address - Country:US
Practice Address - Phone:585-338-1400
Practice Address - Fax:585-336-4845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0185419595OtherGROUP NUMBER FOR BILLING